Provider Demographics
NPI:1235682527
Name:EVOLVE CHIROPRACTIC AND SPORTS REHAB
Entity Type:Organization
Organization Name:EVOLVE CHIROPRACTIC AND SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STOLZEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:262-352-0966
Mailing Address - Street 1:615 MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1517
Mailing Address - Country:US
Mailing Address - Phone:262-352-0966
Mailing Address - Fax:
Practice Address - Street 1:615 MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-1517
Practice Address - Country:US
Practice Address - Phone:262-352-0966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI511812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty